OSEHRA

The merits of open source software are better known today than ever before. No longer is the question whether to use open source, but rather where and how. This has sparked a continuing debate on how to operationalize open source.

From the federal government’s perspective, the how becomes even more interesting, particularly when government regulations come into play. The U.S. Department of Veterans Affairs (VA) chose an innovative approach in 2011, establishing the Open Source Electronic Health Record Alliance (OSEHRA) as a separate non-profit corporation to promote rapid innovation of health IT through open source and community management.

Today, OSEHRA is a rapidly growing open source community with 29 corporate members and over 2,800 individual members representing 160+industry, academic, and government organizations. We are a 501(c) (6) nonprofit that serves the community providing health IT products and services for government, private and global markets. Additionally, we are positioned as the hub of collaboration between government agencies and the private sector that offers a unique model for facilitating the implementation of open source processes into highly structured organizations.

VA’s current electronic health record (EHR) is the Veterans Health Information Systems and Technology Architecture (VistA). VistA is more than just another application – it is a superset of more than 120 applications that operate approximately 150 VA hospitals and 1,000clinics. VistA is highly regarded in the marketplace; in fact, physician user participants in the 2014 Medscape EHR Survey ranked VistA and its CPRS interface as the top EHR in the United States.

The evolution of what is now VistA began in 1977, and its clinician-driven development continues today. As developers began sharing each other’s code with other VA hospitals, VA was one of the few organizations to practice open source before open source became ‘‘cool.” Interestingly, development was actually suspended in 1979, but a group of dedicated volunteers called “Hardhats” continued unofficial collaborative development despite the suspension. This was a precursor of open source development styles common today and eventually resulted in the deployment of VistA throughout VA. By 2010, however, VA recognized that VistA’s rate of innovation and improvement had slowed substantially, and that its code base was unnecessarily isolated from the private sector. At the same time, the health information technology market was booming rapidly due to government incentives stemming from U.S. health care reform. After commissioning studies to develop policy options, VA chose to accelerate innovation by taking advantage of open source. In a sense, VA was going back to its roots, re-adopting the development methodology it championed in the 1980’s and 1990’s before it was known as open source. To accomplish this, VA required an external, independent entity that could act both as the custodian of the open source VistA software and serve as a hub of public-private sector collaboration— OSEHRA.

In 2014, VA established the VistA Intake Program (VIP) to manage the incorporation of open source artifacts into VA enterprise VistA. This move supports the VistA Evolution Program, a modernization effort approved by the U.S. Congress. As open source code intake enhances VistA, the new version will then be released back to the community, thus completing the full cycle of open source activities. The best current example is a new version of Fileman (VistA’s underlying data manager), which has been enhanced by the community and is about to be integrated back into VA.

For many years, VA has periodically released VistA code to the community in compliance with the Freedom of Information Act (FOIA). As a result, FOIA VistA has not only become the core technology of many of today’s commercial EHR products, but it has also been adopted by integrators and providers in the U.S., Europe, and the Middle East. For example, the Hashemite Kingdom of Jordan has implemented a national EHR using VistA. Because VistA code has been in the public domain for many years and adopted by more than 1,500 users without a coordinating body, there are many versions in existence. We are working with our community members to develop a code convergence roadmap, and we are creating OSEHRA VistA to serve as a common core. OSEHRA VistA will be licensed under the Apache Software License, Version 2.0 to provide the community maximum flexibility for additional innovations and reuse.

Even though we will be offering OSEHRA VistA as a core “product,” OSEHRA does not actually develop software. Instead, we provide a contribution, testing, and curation infrastructure that allows our community members to productize the code by adding additional functionality and support services. We provide tools and services such as:

• ViViaN™ (Visualizing VistA and Namespace), a versatile software visualization tool

• Forum, a patch management and distribution tool

• A draft standard for Open Source Software Quality

As open source momentum increases, OSEHRA is broadening its operations to support expanding community interest. For example, over the past several years, the Office of the National Coordinator (ONC) has been developing an application called popHealth® to facilitate reporting for Meaningful Use. Upon completion of initial development efforts in 2014, the community of popHealth developers and users decided make OSEHRA their new home. We have completed the transition of the code into OSEHRA, and the steering committee has developed a code convergence plan. While popHealth was initially developed to generate analytics necessary for Meaningful Use certification, it is now seen as a principal tool for tracking care outcomes in multiple settings, including state Medicaid service, care transition support, and care coordination.

By working with the community, OSEHRA will be expanding its activities into VistA analytics, mobile health, meaningful use, and interoperability in the coming year. Further, there is a growing interest in the global market for open source solutions for health IT, and OSEHRA is fostering international exchanges.

Open source operations in government agencies have some unique challenges. While some agencies have in-house software development activities, most rely on acquisitions for services and products. Thus, the agencies will have to incorporate the advantages and benefits of open source into the acquisition process. The work VA is doing could serve as an excellent case study on how the government and private sector can partner to benefit from open source methodology. We believe, more than ever, that the use of the open source approach will exponentially grow within both the government and private sectors. Our community members deserve a great deal of credit for their contributions and commitment to open source innovation and OSEHRA.